SAMPLE AUTHORIZATION LETTER
Claimant Name (or Auth Rep)
City, State, Zip
Re: Claim Number (Insert Claim Number)
Dear (Insert Claimant or Auth Rep Name):
This letter is in reference to your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received a request for authorization for the (enter purchase or rental) of a (enter the type of DME) for the following covered medical condition(s):
List the condition(s)
After a thorough review of your case file, including communication with your treating physician (if applicable), the following authorization is granted:
Rental of [enter type of DME and billing code] for the period of [enter to and from date] from (enter vendor name).
Purchase of [enter type DME and billing code] from (enter vendor name).
Please note that the DEEOIC requires that the approved vendor noted above be enrolled as a provider in our medical bill payment system to be reimbursed. Vendors may call toll free 1-866-272-2682 for program enrollment information or for answers to payment questions.
All fees for the rental/purchase of DME are subject to the OWCP fee schedule. Furthermore, if the rental of DME is converted to a purchase, the costs incurred for the rental of that item will be deducted from the purchase reimbursement price.
Add-ons and/or upgrades to DME will be considered for approval if evidence substantiates a medical need for the enhancement. However, add-ons and/or upgrades to DME are not covered when they are intended primarily for the claimant’s convenience and do not significantly enhance DME functionality.
If you have any questions or concerns regarding this authorization, please call your claims examiner at (XXX) XXX-XXXX.
(Insert CE name)
DEEOIC Claims Examiner
cc: (enter supplier name)